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Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 159-164

Neonatal outcome of twins and singleton neonates: An experience from tertiary care teaching center of Eastern Maharashtra, India

Department of Paediatrics, Government Medical College, Nagpur, Maharashtra, India

Date of Submission11-May-2022
Date of Decision16-May-2022
Date of Acceptance18-May-2022
Date of Web Publication06-Jul-2022

Correspondence Address:
Rajkumar Motiram Meshram
Department of Paediatrics, Government Medical College, Nagpur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.jcn_50_22

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Introduction: It is impossible to achieve the target of Sustainable Developmental Goal without focusing on care of twins' neonates as they are more prone for death and higher chance of long-term morbidity and neurodevelopmental handicap in survivors. Aim: To estimate the outcome among twin and singleton neonates at a tertiary care teaching center of Eastern Maharashtra. Materials and Methods: Prospective observational study was conducted on neonatal intensive care unit graduates of twin birth and simultaneously admitted singletons at Government Medical College and Hospital Nagpur from June 2020 to February 2021 (9 months). Outcome among twin and singleton neonates, and their morbidity and mortality pattern were studied. Results: A total of 210 neonates of twin birth and 870 singleton neonates were recruited. Male were dominant in both groups. Preterm and low birth weight neonates were significantly more in twins compared to singleton neonates. Twin neonates were significantly more hypothermic (P < 0.001) and hypoxic (P = 0.001) compared to singleton. Jaundice (37.62%) and respiratory distress syndrome (36.67%) were the most common diagnosis in twin neonates while sepsis (34.71%) was predominant in singleton. Sepsis (33.9%) was the most common cause of death in singleton neonates while respiratory distress syndrome (35.38%) in twin births. Length of hospital stay (P < 0.0001) and neonatal mortality were significantly higher in twin neonates compared to singleton neonates (P = 0.001). Conclusion: Sepsis is the leading cause of admission and death in singleton neonates while respiratory distress syndrome in twins. Twin neonates have significantly higher mortality and longer hospital stay because of prematurity and low birth weight.

Keywords: Central India, multiple births, neonatal mortality, neonatal morbidity

How to cite this article:
Meshram RM, James A. Neonatal outcome of twins and singleton neonates: An experience from tertiary care teaching center of Eastern Maharashtra, India. J Clin Neonatol 2022;11:159-64

How to cite this URL:
Meshram RM, James A. Neonatal outcome of twins and singleton neonates: An experience from tertiary care teaching center of Eastern Maharashtra, India. J Clin Neonatol [serial online] 2022 [cited 2023 Mar 28];11:159-64. Available from: https://www.jcnonweb.com/text.asp?2022/11/3/159/350035

  Introduction Top

Twin pregnancy is the result of complex interaction between not only genetic factors but also factors such as advanced maternal age/parity, high socioeconomic status, and use of assisted reproductive technology.[1] The prevalence of twin pregnancy has increased in last three decades mainly in high and middle income countries. The rate of dizygotic twinning has mainly contributed for increase of twin birth whiles the rate of monozygotic twin remains constant.[2],[3],[4] The rate of natural twinning is low in East Asia, intermediate in Europe, USA, and high in sub-Saharan Africa especially in Nigeria.[3],[5],[6] In India, the rate of twin pregnancy varies from 3-7 per thousand deliveries.[3],[7],[8]

Twin pregnancies are high risk pregnancies due to inherent biological factors leading to increased rates of obstetrics and perinatal complications and such pregnancies in low-resources setting enhance feto-maternal risk due to limited availability of human and material resources. Due to increase in rate of caesarean delivery and neonatal intensive care unit (NICU) admission, neonates born to multiple pregnancies have threefold higher economic burden on health care system.[2] It is impossible to achieve the every newborn 2035 target of less than ten neonatal deaths per thousand live births and the Sustainable Developmental Goal 2030 targets without targeting such high risk neonates, as multiple births are associated with a four-fold increase in foetal deaths and six-fold increase in neonatal deaths compared to singleton neonates.[4],[5],[9]

Twins are extremely vulnerable due to preterm births, fetal growth restriction, low birth weight, intrapartum anoxia, and birth weight differences among them and these are the important independent risk factors of mortality.[10],[11],[12],[13] Neonatal morbidity such as retinopathy of prematurity, respiratory distress syndrome, increased chances of sepsis/jaundice, and neurodevelopmental handicap are more in twin neonates compared to singleton due to prematurity.[14],[15],[16] Discordance between weights among twin, twin to twin transfusion syndromes are peculiarly observed in twin neonates. Comparative data of twin and singleton neonates are mainly noted and published by obstetrician and mainly emphasizes on maternal complication compared to detail about neonates. Hence, this study was conducted to estimate the morbidity and mortality pattern among twin and singleton neonates from Eastern Maharashtra.

  Materials and Methods Top

This prospective observational study was conducted on neonates who were born to mothers with twin pregnancy and required NICU admission; and simultaneously NICU admitted singletons neonates at Government Medical College and Hospital Nagpur from June 2020 to February 2021 (9 months). Our hospital is a 1200 bedded tertiary health care facility. Every month around 1200–1500 pregnant mothers deliver and around 10–15 neonates are daily admitted in NICU. Our NICU is equipped with radiant warmer, phototherapy units, central oxygen supply, bubble continuous positive airway pressure, neonatal ventilators, and facilities for dialysis and surfactant therapy.

The sample size was calculated by assuming the prevalence of twin birth is 5%, absolute precision of 3% and confidence interval of 95%; and by using following formula: N = Z21−α P (1 − p)/d2 Where; N = Number of sample, α = level of significance, Z1-α = Corresponding normal standard variant, P = Expected proportion, d = Absolute precision and the sample size was 203. But we recruited 210 neonates consequently born to mothers with twin gestations those required NICU admission and simultaneously recruited NICU admitted singletons neonates over a period of 9 months after approval from Institutional Ethics Committee (No. 2045 EC/Pharmac/GMC/NGP Date May 04, 2020) and informed valid consent from parents. Neonates whose parents left the hospital against medical advice and those not willing to participate in the study were excluded.

Data were collected following admission, from either the mother or the caregiver in a structured data sheet. Maternal details including age, gravida/parity status, obstetrics complications, and mode of delivery were recorded. All the neonates were attended by residents posted in the neonatology unit. Neonatal data included gestational age (assessed by either menstrual history of mother, available ultrasound report or by New Ballard Scoring), gender, birth weight, clinical presentation, and duration of hospital stay. All neonates were investigated, managed and monitored as per the standard treatment protocol till discharge or death. Diagnosis of neonatal illness and estimation of the cause of death was done using clinical information and necessary laboratory investigation.

Statistical analysis

The data were entered into Microsoft Excel sheet and analysis was done using software STATA version 14, developed by StataCorp 4905 Lakeway Drive, College Station, Texas 77845-4512 (USA). The data regarding the numerical variables were summarized through percentage, average, and deviation pattern. Comparisons of categorical data were carried out using the Pearson's Chi-square & Fisher's exact test. P < 0.05 was taken as statistically significant.

  Results Top

A total of 210 neonates born to twin pregnancies and 870 singleton neonates were admitted during the study period. The male-to-female ratio was 1.14: 1 and 1.3:1 in twin and singleton neonates, respectively. Early preterm neonates (14.29% vs. 7.93%) (P = 0.006) and late preterm (37.62% vs. 20.8%) (P < 0.001) were significantly more in twins while term (49.66% vs. 23.81%) in singleton. Low birth weight neonates (88.1% vs. 66.55%) were significantly higher in twin compared singleton neonates (P < 0.001). Clinical presentation and morbidity pattern of singleton and twin neonates are tabulated in [Table 1].
Table 1: Demographic characteristics, clinical presentation and morbidity patterns of twin and single neonates

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A significant difference was observed in mothers of twin neonates with previous infertility (P < 0.001), abortion (P = 0.001), and still birth (P = 0.001) compared to singleton mothers as well as anemia (P < 0.001), diabetes (P < 0.001), and hypertension (P = 0.001) were significantly higher in mothers of twin neonates compared to single neonate mothers likewise obstetrics complications were significantly more in mothers with twin delivery [Table 2].
Table 2: Maternal variables of study participants

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A significant difference was found between single and twin neonates on mean length of hospital stay (P < 0.001) and neonatal mortality was significantly higher in twin neonates compared to single neonates (30.94% vs. 20.34%) (P = 0.001). Sepsis (33.9%) was the most common cause of death followed in singleton neonates while respiratory distress syndrome (35.38%) was the most common cause of death in twin neonates [Table 3]. Twin extreme preterm (23.08% vs. 1.7% [P < 0.001]) and early preterm (33.85% vs. 9.6% [P < 0.001]) neonates had significantly higher mortality compared to same gestational age of singleton neonates while term neonates of singleton (59.3% vs. 7.69%) had better chance of survival [P < 0.001, [Figure 1] and [Figure 2]].
Table 3: Mortality pattern of study participants

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Figure 1: Gestational age-wise mortality in singleton neonates

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Figure 2: Gestational age-wise mortality in Twin neonates

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  Discussion Top

In the present study, premature and low birth weight neonates were significantly more in twins as compared to singleton as well as twin neonates were significantly more hypothermic and hypoxic. Sepsis was the most common cause of admission and death in singleton neonates while jaundice was the most common morbidity and respiratory distress syndrome was the leading cause of mortality in twin babies. Length of hospital stay as well as mortality was significantly more in twin neonates compared to singleton neonates. History of infertity, previous abortion, and still birth were significantly higher in twins mothers compared to mothers of singleton neonates.

Twin pregnancies have a negative impact on perinatal health indicators and are associated with high risk of complications for both mother and baby. Twin births rates are extremely variable around the world and higher in countries with higher human development index. Advanced maternal age, parity, and familial trend of multiple birth are associated with dizygotic multiple pregnancies, but monozygotic multiple births are not influenced by maternal age but they are associated with genetics.[1],[3] In our study, history of infertity, previous abortion, and still birth were significantly higher in mothers with twins compared to singleton, might be because of utilization of ovulation inducing agent for infertility, but we were unable to find the significant difference between the age and parity of mother of singleton and twins. However a multi country cross-sectional survey by the WHO revealed mothers of twins were older and of higher parity.[2] Mothers of twin neonates had significantly higher incidence of anemia, hypertensive disorder, hypothyroidism, sickle cell disease, and diabetes in comparison with mothers of singleton neonates. Similarly, obstetric complications (pregnancy-induced hypertension, eclampsia, antepartum hemorrhage, malpresentation, and premature rupture of membrane) were significantly more in mothers with twin compared to singleton. Our findings are in agreement with observations of various reachers,[2],[3],[17],[18],[19] but Papiernik et al.[20] revealed lower prevalence of maternal hypertension and hemorrhage in their prospective study.

Like us Sabzehei et al.[21] and Kalikkot Thekkeveedu et al.[22] did not find the difference between the gender distribution among the twin and singleton neonates but Olusanya[6] from Nigeria observed neonates born to multiple pregnancies were more likely to be female. Low birth weight and intrauterine growth restriction in twins are constant finding in literature and responsible for various morbidities and mortality.[6],[19],[21],[23] We observed 88.1% twins are low birth weight compared to 66.5% singleton neonates. Higher odds ratio was observed by Olusanya[6] for LBW (odds ratio [OR] 6.45, P < 0.001) and IUGR (OR 9.04, P < 0.001) of multiple births compared to singletons while significantly higher number of LBW and IUGR twins are noted by other authors.[19],[21],[23] However, Cheung et al. noted significant pattern of difference in the weight and length between twin and singletons those born over 32 weeks of gestational age while they minimally differ among those of 28–32 weeks of gestational age.[24]

Premature birth is one of the important determinanants of survival and neurodevelopmental outcome of neonates. In the present study, preterm babies are significantly more in twin compared to singleton and among preterm neonates; early and late preterm were significantly more in twins and our results are in agreement with results of other authors.[2],[6],[13],[14],[15],[16] Refuerzo et al. observed moderate preterm (14.5%) and late preterm (49.8%) in twin neonates in their multicenter randomized trial; and they also observed higher rates of neonatal morbidities in late and moderate preterm compared to twins born at term.[25] A cohort study done by Murray et al.[26] from Northern Scotland observed most of the perinatal deaths in extreme preterm period and increase risk of mortality in twin neonates delivered at or above 39 weeks after adjusting potential confounders. Cheung et al.[24] postulated on Swedish Medical Birth Registry data that twins have better health than singletons initially but they could not enjoy the benefit of a longer gestational duration as much as singletons could. Papiernik et al.[20] also noted higher risk of mortality and severe cranial hemorrhage in very preterm twins than singletons if they were from same sex pairs with discordant birth weights.

In our study, jaundice (P = 0.001) and respiratory distress syndrome (P < 0.001) are significantly more in twin neonates compared to singleton while sepsis, birth asphyxia, meconium aspiration syndrome dominated in single birth but congenital anomalies are almost equal in both. Equal incidence of congenital malformation is reported by Su et al.[17] (0.8% vs. 0.6%) and Gupta et al.[19] (2% vs. 2.2%) in twin and singleton births. Recent data of Brazil Birth revealed higher odds of jaundice and antibiotics use in late preterm; and higher odds for oxygen use, transient tachypnea in early preterm twins while second born twin had an elevated likelihood of jaundice, antibiotic use and oxygen therapy compared to first-born neonates.[13] Low Apgar and higher incidence of hyperbilirubinemia, respiratory distress syndrome and need of hospitalization is also revealed by Sabzehei et al.[21] and Singh and Trivedi[23] while higher incidence of sepsis, low Apgar score and hyperbilirubinemia but no significant difference in congenital anomalies, sensorineural hearing loss in Nigerian study.[6] Higher odds of pulmonary hemorrhage and severe intraventricular hemorrhage while surprisingly low odds of respiratory distress syndrome, bronchopulmonary dysplasia and bacterial sepsis in twin compared to single birth are noted by Kalikkot Thekkeveedu et al.[22]

We found that length of hospital stay is significantly longer in twin neonates compared to the singleton. Kalikkot Thekkeveedu et al. reported longer duration of hospital stay in multiple gestation birth, including twin, triplet, and higher order multiple birth while Vachharajani et al. observed longer hospital stay for twin and triplet compared to singleton neonates born at 34 weeks, but it is comparable for twin and triplet to that of singleton at 35 and 36 weeks while few authors found no difference in the duration of hospital stay between singleton and twin births.[27]

Although mortality is higher in twin birth, Murray et al.[26] observed higher perinatal deaths in twin born beyond 39 weeks compared to 37–38 weeks gestation as well as two fold more perinatal mortality in monochorionic twin compared to dichorionic twins and without any difference in mortality between naturally conceived and twin via assistance of artificial reproductive technology. However a population based model showed twin born at 29 and 37 weeks gestation had a lower mortality compared to single birth of same gestational age and twins of older gestational age had higher mortality compared to singleton, because longer gestational duration is more beneficial to singleton compared to twin neonates.[24] Similar to the finding of various authors, neonatal mortality rate was significantly higher for twins compared to singleton (P = 0.001).[2],[3],[5],[6] Respiratory distress syndrome was the most common cause of death in twins due to preterm birth complication while sepsis was the leading cause of death in singleton.


Main limitation of this study is the inclusion of a single center for a shorter duration.

  Conclusion Top

Twin neonates have significantly higher mortality and longer hospital stay because of prematurity, low birth weight as well as they are more prone for hypothermia and hypoxia. Sepsis is the leading cause of admission and death in singleton neonates while respiratory distress syndrome is the most common cause of mortality in twins due to preterm birth complication.


It is vital to identify twin pregnancy, provide effective antenatal care by obstetrician as well as anticipation and prompt treatment of twin neonates to reduce the neonatal mortality and ultimately to achieve the SDG.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Smits J, Monden C. Twinning across the developing world. PLoS One 2011;6:e25239.  Back to cited text no. 3
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Monden CW, Smits J. Mortality among twins and singletons in sub-Saharan Africa between 1995 and 2014: A pooled analysis of data from 90 Demographic and Health Surveys in 30 countries. Lancet Glob Health 2017;5:e673-9.  Back to cited text no. 5
Olusanya BO. Perinatal outcomes of multiple births in southwest Nigeria. J Health Popul Nutr 2011;29:639-47.  Back to cited text no. 6
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Beiguelmn B, Franchi-Pinto C. Perinatal mortality among twin and singleton in a city in southeastern Brazil, 1984-1996. Gen Mol Biol 2000;23:15-23.  Back to cited text no. 12
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Riazi-Esfahani M, Alizadeh Y, Karkhaneh R, Mansouri MR, Kadivar M, Nili Ahmadabadi M, et al. Retinopathy of prematurity: Single versus multiple-birth pregnancies. J Ophthalmic Vis Res 2008;3:47-51.  Back to cited text no. 14
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Santana DS, Silveira C, Costa ML, Souza RT, Surita FG, Souza JP, et al. Perinatal outcomes in twin pregnancies complicated by maternal morbidity: Evidence from the WHO multicounty survey on maternal and newborn health. BMC Pregnancy Childbirth 2018;18:449.  Back to cited text no. 18
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Vachharajani AJ, Vachharajani NA, Dawson JG. Comparison of short-term outcomes of late preterm singletons and multiple births: An institutional experience. Clin Pediatr (Phila) 2009;48:922-5.  Back to cited text no. 27


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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